Impact of the COVID-19 Pandemic on Brazilian Head and Neck Surgery Centers

Abstract Objective The outbreak of the COVID-19 pandemic had a considerable impact on the healthcare access, treatment, and follow-up of oncologic patients. The aim of this study was to evaluate how the COVID-19 pandemic has affected consultation and follow-up demand as well as treatment volume at Brazilian Head and Neck Surgery centers. Methods An anonymous online questionnaire was used for collection of data across all Brazilian Head and Neck Surgery Centers across a 3-month period (April‒June 2021). This information included the characteristics of each center, and the perceived self-reported impact of the COVID-19 pandemic on academic activities, residency training, and the diagnosis, treatment, and follow-up of patients with Head and Neck diseases between 2019 and 2020. Results The response rate across the 40 registered Brazilian Head and Neck Surgery Centers was 47.5% (n = 19). The data showed a significant reduction in the total number of consultations (24.8%) and number of attending patients (20.2%) between 2019 and 2020. The total number of diagnostic exams (31.6%) and surgical procedures (13.0%) conducted over this period also decreased significantly. Conclusions The COVID-19 pandemic had a significant national impact on Brazilian Head and Neck Surgery Centers. Future studies should examine the long-term effects of the pandemic on cancer treatment. Level of evidence Evidence from a single descriptive study.

Impact of the COVID-19 Pandemic on Brazilian Head and Neck Surgery Centers.

OBJECTIVE: The outbreak of the COVID-19 pandemic had a considerable impact on the healthcare access, treatment, and follow-up of oncologic patients. The aim of this study was to evaluate how the COVID-19 pandemic has affected consultation and follow-up demand as well as treatment volume at Brazilian Head and Neck Surgery centers. METHODS: An anonymous online questionnaire was used for collection of data across all Brazilian Head and Neck Surgery Centers across a 3-month period (April‒June 2021). This information included the characteristics of each center, and the perceived self-reported impact of the COVID-19 pandemic on academic activities, residency training, and the diagnosis, treatment, and follow-up of patients with Head and Neck diseases between 2019 and 2020. RESULTS: The response rate across the 40 registered Brazilian Head and Neck Surgery Centers was 47.5% (n=19). The data showed a significant reduction in the total number of consultations (24.8%) and number of attending patients (20.2%) between 2019 and 2020. The total number of diagnostic exams (31.6%) and surgical procedures (13.0%) conducted over this period also decreased significantly. CONCLUSIONS: The COVID-19 pandemic had a significant national impact on Brazilian Head and Neck Surgery Centers. Future studies should examine the long-term effects of the pandemic on cancer treatment. LEVEL OF EVIDENCE: Evidence from a single descriptive study.

Comparative analysis of the bronchoalveolar microbiome in Portuguese patients with different chronic lung disorders.

The lung is inhabited by a diverse microbiome that originates from the oropharynx by a mechanism of micro-aspiration. Its bacterial biomass is usually low; however, this condition shifts in lung cancer (LC), chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). These chronic lung disorders (CLD) may coexist in the same patient as comorbidities and share common risk factors, among which the microbiome is included. We characterized the microbiome of 106 bronchoalveolar lavages. Samples were initially subdivided into cancer and non-cancer and high-throughput sequenced for the 16S rRNA gene. Additionally, we used a cohort of 25 CLD patients where crossed comorbidities were excluded. Firmicutes, Proteobacteria and Bacteroidetes were the most prevalent phyla independently of the analyzed group. Streptococcus and Prevotella were associated with LC and Haemophilus was enhanced in COPD versus ILD. Although no significant discrepancies in microbial diversity were observed between cancer and non-cancer samples, statistical tests suggested a gradient across CLD where COPD and ILD displayed the highest and lowest alpha diversities, respectively. Moreover, COPD and ILD were separated in two clusters by the unweighted UniFrac distance (P value = 0.0068). Our results support the association of Streptoccocus and Prevotella with LC and of Haemophilus with COPD, and advocate for specific CLD signatures.

Use of Single Chimeric Free Flaps or Double Free Flaps for Complex Head and Neck Reconstruction.

BACKGROUND: Free flaps have become the preferred reconstructive approach to restore form and function for patients presenting with complex head and neck defects. For composite, complex defects for which a regular free flap might not meet all reconstructive demands, adequate coverage can be achieved with either a single chimeric free flap or a double free flap. METHODS: We performed a single-center retrospective chart review of patients who underwent either single chimeric free flap or double free flap reconstruction. Indications for reconstruction included defects resultant from head and neck tumor or osteoradionecrosis resections. We extracted the following variables: tumor location, defect, flap(s) performed, and postoperative complications. Unpaired t-tests were performed to evaluate for statistically significant differences in complications encountered between the single chimeric versus the double free flap patient groups. RESULTS: In our series of 44 patients, a total of 55 single chimeric and double free flaps were performed. We found no significant difference in overall complications (p = 0.41) or flap/skin paddle loss (p = 0.45) between the groups. There were three total flap losses; two patients underwent successful salvage procedures and one patient died. The anterolateral thigh (ALT) was the most common free flap (70%) used in our series, and 98% of our patients completed successful reconstruction. CONCLUSION: As the initial reconstructive effort is critical for achieving favorable long-term outcomes in complex head and neck cases, effective and safe techniques should be employed to ensure optimal delivery of care. We believe that single chimeric and double free flap techniques should be appropriately utilized as part of the armamentarium of head and neck reconstructive microsurgeons.

Fascicular Turnover Flap: An Approach for Facial Nerve Reconstruction.

ABSTRACT: Facial nerve injuries are a common complication associated with parotidectomy. These functionally debilitating injuries are conventionally treated with nonvascularized nerve grafting; however, this reconstructive modality produces moderate donor site morbidity and has limited efficacy for repairing large defects. In addition, nonvascularized nerve grafts are highly susceptible to radiotherapy and require a well-vascularized wound bed to produce adequate therapeutic results. The fascicular turnover flap, described by Koshima et al, utilizes a single fascicle to bridge two nerve endings that are in series with no donor site morbidity. Although studies have demonstrated this technique's efficacy, there is a paucity of data regarding its use in patients undergoing facial nerve reconstruction. Herein, we describe our early clinical experience using the fascicular turnover flap to reconstruct branches of the facial nerve in patients undergoing extensive parotidectomy. Our patients underwent successful reconstruction of the nerve defects produced by parotidectomy using the fascicular turnover flap. Despite postoperative radiotherapy, both patients demonstrated complete functional recovery at six months postoperatively. Although formal head-to-head studies are needed to compare the outcomes of this technique versus conventional nerve grafting for facial nerve reconstruction, our preliminary experiences suggest that the fascicular turnover flap is a viable modality of reconstruction with great potential.

Profiling of lung microbiota discloses differences in adenocarcinoma and squamous cell carcinoma.

The lung is a complex ecosystem of host cells and microbes often disrupted in pathological conditions. Although bacteria have been hypothesized as agents of carcinogenesis, little is known about microbiota profile of the most prevalent cancer subtypes: adenocarcinoma (ADC) and squamous cell carcinoma (SCC). To characterize lung cancer (LC) microbiota a first a screening was performed through a pooled sequencing approach of 16S ribosomal RNA gene (V3-V6) using a total of 103 bronchoalveaolar lavage fluid samples. Then, identified taxa were used to inspect 1009 cases from The Cancer Genome Atlas and to annotate tumor unmapped RNAseq reads. Microbial diversity was analyzed per cancer subtype, history of cigarette smoking and airflow obstruction, among other clinical data. We show that LC microbiota is enriched in Proteobacteria and more diverse in SCC than ADC, particularly in males and heavier smokers. High frequencies of Proteobacteria were found to discriminate a major cluster, further subdivided into well-defined communities' associated with either ADC or SCC. Here, a SCC subcluster differing from other cases by a worse survival was correlated with several Enterobacteriaceae. Overall, this study provides first evidence for a correlation between lung microbiota and cancer subtype and for its influence on patient life expectancy.

Educational interventions to improve inhaler techniques and their impact on asthma and COPD control: a pilot effectiveness-implementation trial / Educação para a melhora da técnica inalatória e seu impacto no controle da asma e DPOC: um estudo piloto de efetividade-intervenção

ABSTRACT To assess the impact that educational interventions to improve inhaler techniques have on the clinical and functional control of asthma and COPD, we evaluated 44 participants before and after such an intervention. There was a significant decrease in the number of errors, and 20 patients (46%) significantly improved their technique regarding prior exhalation and breath hold. In the asthma group, there were significant improvements in the mean FEV1, FVC, and PEF (of 6.4%, 8.6%, and 8.3% respectively). Those improvements were accompanied by improvements in Control of Allergic Rhinitis and Asthma Test scores but not in Asthma Control Test scores. In the COPD group, there were no significant variations. In asthma patients, educational interventions appear to improve inhaler technique, clinical control, and functional control.

RESUMO Para avaliar o impacto do ensino da técnica inalatória no controle clínico e funcional de pacientes com asma ou DPOC, incluíram-se 44 participantes antes e após essa intervenção. Houve uma diminuição significativa no número de erros cometidos, sendo que 20 pacientes (46%) melhoraram significativamente sua técnica na expiração prévia e apneia final. No grupo asma, houve significativa melhora nas médias de FEV1 (6,4%), CVF (8,6%) e PFE (8,3%), e essa melhora correlacionou-se com os resultados no Control of Allergic Rhinitis and Asthma Test, mas não com os do Asthma Control Test. No grupo DPOC, não houve variações significativas. O ensino da técnica inalatória parece melhorar seu desempenho e os controles clínico e funcional em pacientes com asma.

BRAF mutation in papillary thyroid cancer and its value in tailoring initial treatment: a systematic review and meta-analysis.

Clinicians have long sought to characterize biological markers of neoplasia as objective indicators of tumor presence, pathogenicity, and prognosis. Armed with data that correlate biomarker activity with disease presence and progression, clinicians can develop treatment strategies that address risks of disease recurrence or persistence and progression. The B-type Raf kinase (BRAF V600E) mutation in exon 15 of the BRAF gene has been noted to be a putative prognostic marker of the most prevalent form of thyroid cancer, papillary thyroid cancer (PTC)--a tumor type with high proclivity for recurrence or persistence. There has been a remarkable interest in determining the association of BRAF mutation with PTC recurrence or persistence. Using many new studies that have been published recently, we performed a meta-analysis to investigate correlations of BRAF mutation status with PTC prognosis, focusing on the recurrence or persistence of the disease after initial treatment. The study was based on published studies included in the PubMed and Embase databases addressing the BRAF mutation and the frequency of recurrence of PTC. We selected studies with data that enabled measurement of the risk ratio for recurrent disease. We also analyzed the factors that are classically known to be associated with recurrence. These factors included lymph node metastasis, extrathyroidal extension, distant metastasis, and American Joint Committee on Cancer (AJCC) stages III/IV. We used 14 articles that included an analysis of these factors as well as PTC recurrence data, with a total of 2470 patients from 9 different countries. The overall prevalence of the BRAF mutation was 45%. The risk ratios in BRAF mutation-positive patients were 1.93 (95% confidence interval [CI], 1.61-2.32; Z = 7.01; p < 0.00001) for PTC recurrence, 1.32 (95% CI, 1.20-1.45; Z = 5.73; p < 0.00001) for lymph node metastasis, 1.71 (95% CI, 1.50-1.94; Z = 8.09; p < 0.00001) for extrathyroidal extension, 0.95 (95% CI, 0.63-1.44; Z = 0.23; p = 0.82) for distant metastasis, and 1.70 (95% CI, 1.45-1.99; Z = 6.46; p < 0.00001) for advanced stage AJCC III/IV. Thus, in this meta-analysis, the BRAF mutation in PTC was significantly associated with PTC recurrence, lymph node metastasis, extrathyroidal extension, and advanced stage AJCC III/IV. Patients with PTC harboring mutated BRAF are likely to demonstrate factors that are associated with an increased risk for recurrence of the disease, offering new prospects for optimizing and tailoring initial treatment strategies to prevent recurrence.

Incidence of malignancy in thyroid nodules determined to be follicular lesions of undetermined significance on fine-needle aspiration.

BACKGROUND: Fine-needle aspiration (FNA) for thyroid nodules is the most important method for determining a diagnosis. The system for reporting results is based on a cytopathologic classification that stratifies the risk of malignancy. METHODS: We retrospectively studied 197 patients who underwent FNA for diagnostic evaluation of a thyroid nodule and had their results reported as a follicular lesion of undetermined significance (FLUS) using the Bethesda classification system. The objective of the study was to analyze the incidence and histopathologic types of malignancy in these cases. RESULTS: The final histopathologic breakdown is as follows: 65 cases (32.9%) of follicular adenoma, 81 cases (41.1%) of microfollicular adenomatoid nodule, 19 cases (9.6%) of microfollicular adenomatoid nodule on the background of thyroiditis, 17 cases (8.6%) of follicular carcinoma, 9 cases (4.6%) of follicular variant papillary carcinoma, and 6 cases (3.1%) of classic papillary carcinoma, for a 16.2% incidence of malignancy. Beyond these diagnoses in the FNA-biopsied nodules, we observed 29 cases (14.7%) of incidental ipsilateral papillary thyroid microcarcinoma (PTM) and 13 cases (6.6%) of incidental contralateral thyroid lobe PTM. CONCLUSIONS: This study observed a 16.2% incidence of thyroid cancer in the nodule designated FLUS compared to the 5 to 15% rate reported by the Bethesda FNA classification. The overall incidence of incidental PTM in the thyroid gland was 21.3%. These data support considering surgical intervention for at least diagnostic purposes in a patient with the FNAB diagnosis of FLUS.

The incidence of central neck micrometastatic disease in patients with papillary thyroid cancer staged preoperatively and intraoperatively as N0.

BACKGROUND: In papillary thyroid cancer, the incidence of regional lymph node metastasis in the central compartment has been reported to be between 21% and 60%. This study sought to establish the rate of micrometastatic disease in the central neck in patients staged as N0 by preoperative and intraoperative assessment. METHODS: We studied 72 consecutive patients with diagnoses of papillary thyroid cancer without preoperative or intraoperative evidence of central neck metastases. They underwent total thyroidectomies and were given elective central compartment neck dissection (CCND) ispsilateral to the lobe harboring the tumor or bilaterally in cases of primary tumor located in the isthmus. RESULTS: Of the patients, 30 underwent right CCND, 30 underwent left CCND, and in 12 cases the dissection was bilateral. The incidence of lymph node micrometastasis was 25%. Male gender and histologic type showed association with lymph node micrometasis. Among these cases, 7% had temporary vocal cord palsy, and 8% had temporary hypoparathyroidism. No cases of definitive vocal cord palsy or definitive hypocalcemia were observed. After the procedure 8 patients were up-staged according to the American Joint Committee on Cancer staging system. CONCLUSION: Despite being a safe procedure, this relatively low rate of micrometastatic disease emphasizes the need for a careful weighing of the risks and benefits of elective CCND.

Reconstrução de mandíbula com retalho microcirúrgico: relato de três casos / Mandible reconstruction with microsurgical flaps: three cases report

Relatar a experiência com a reconstrução microcirúrgica de mandíbula com três procedimentos diferentes. Método: analisaram-se três casos de reconstrução de mandíbula com retalho microcirúrgico, utilizando-se os ossos da fíbula, metatarso e rádio, para o tratamento de defeitos mandibulares por ressecções de tumores. A indicação, técnica e evolução dos procedimentos são relatadas. Resultados: um caso de ressecção mandibular por osteossarcoma foi reconstruído com retalho microcirúrgico, utilizando a fíbula, e dois casos de carcinoma epidermóide de boca recidivados, com invasão mandibular, foram reconstruídos com metatarso e rádio respectivamente. Conclusão: os retalhos microcirúrgicos constituíram uma boa opção terapêutica para os casos de reconstrução de defeitos mandibulares...

Estesioneuroblastoma / Esthesioneuroblastoma

O Estesioneuroblastoma (ENB) é um tumor maligno raro, originado da crista neural, crescendo na cavidade nasal. Objetivo: descrever um caso de ENB, com abordagem multidisciplinar, cuja manifestação clínica inicial foi proptose ocular, que é uma de suas apresentações mais raras. Método: relato de caso de um paciente de doze anos, masculino, portador de ENB, analisando a forma de manifestação clínica, método diagnóstico empregado e tratamento realizado. Resultados: a manifestação clínica inicial foi a proptose ocular esquerda, sendo submetido, em outro serviço médico, à cirurgia com ressecção parcial do tumor e quimioterapia. Em função da persistência tumoral, foi submetido à nova avaliação e ao tratamento definitivo, através de cirurgia craniofacial, com ressecção tumoral completa, reconstrução com retalho microcirúrgico do músculo reto abdominal e radioterapia adjunvante. Atualmente, no nono mês pós-operatório, sem sinais de doença ativa. Conclusão: o trabalho mostra a abordagem terapêutica multimodal, com ênfase no tratamento cirúrgico, manifestação clínica infreqüente, diagnósticos diferenciais e modo de reconstrução empregado...

Implicações prognosticas da morfometria das regiões organizadas nucleolares argirófilas no carcinoma epidemóide de língua oral e soalho bucal

As regiões organizadoras nucleolares argirófilas (AgNORs) representam um marcador de proliferação celular relacionado às proteínas presentes no nucléolo, responsáveis pela transcrição nuclear, que são detectadas em nível óptico pela impregnação com prata. O objetivo do presente estudo dói avaliar as implicações prognosticas da morfometria dessas regiões, através de método de análise de imagem, em doentes portadores de carcinoma epidermóide de língua oral e soalho bucal. A morfometria das regiões organizadoras nucleolares foi estudada em lâminas de espécimes cirúrgicos fixaos e incluídos em paafina de 43 doentes portadores de carcinoma epidermóide de língua oral e soalho bucal, estádio clínico II, tratados por ressecção cirúrgica do tumor primário e esvaziamento cervical eletivo. Outros atores histopatológicos, relacionados ao prognóstico desses doentes, foram analisados e tiveram seus resultados comparados aos do método em estudo. A recorrência do carcinoma, o tempo livre de doença e o tempo de sobrevida constituíram variáveis dependentes da morfometria das AgNORs. Valores altos da morfometria das AgNORs, com áreas acima de 7,79um2/núcleo, foram associados a um maior risco de recorrência do carcinoma, menor tempo livre de doença e tempo de sobrevida, mais curto. A morfometria das AgNORs, quando comparada ao grau de diferenciação histológica, à metástase linfodonal microscópica, ao comprometimento de margens cirúrgicas, à espessura do tumor primário e à invasão vascular por células neoplásicas, mostrou uma melhor correlação em predizer a recorrência do carcinoma, e o tempo livre da doença, revelando ser, um método útil, em selecionar os doentes que evoluíram com um pior prognóstico.

Argyrophilic nucleolar organizer regions (AgNORs) represents a tissue marker of cell proliferative activity that detects nucleolar proteins associated with transcription activity analyzed at the optical level by means of argyrophilic staining technique. The purpose of this study was to assess the prognostic value of the AgNORs morphometry in oral tongue and floor of the mouth squamous cell carcinoma. The AgNORs morphometry was studied in paraffin sections by means of digital image analysis in tumor specimens of 43 cases of stage II oral tongue and floor of the mouth squamous cell carcinoma, treated by surgical resection of the primary tumor and elective neck dissection. The results were compared with the histopathological data. Tumor recurrence, disease-free interval and long term survival were considered a dependent variable of a binary indicator of AgNORs morphometry. High values of AgNORs area (>7,79 mm2/nucleus) were associated with high incidence of tumor recurrence, reduction on recurrence-free interval of disease and reduction on long term survival. When compared to degree of histologic differentiation, microscopic lymph node metastasis, involvement of the surgical margins, lesion thickness and vascular invasion by cancer cells, showed a better correlation to predict cancer recurrence and disease-free interval. The AgNORs morphometry was able to increase the capabiblity of selecting those patients with poor prognosis.

Câncer de boca, um problema crescente e alarmante no nosso meio / Oral cancer, an increasing problem

O câncer de boca figura como o sexto tipo de câncer mais frequente no mundo e apesar de toda a evoluçäo tecnológica da medicina observada nas últimas décadas as taxas de mortalidade na maioria dos países desenvolvidos permanece constante e proibitiva. Neste artigo säo discutidos os principais fatores responsáveis pela situaçäo grave na qual se encontra a abordagem do câncer de boca, bem como estratégias para modificaçäo deste panorama sombrio nos dias atuais com atençäo especial à prevençäo e ao diagnóstico precoce.

Protocolo de tratamento do câncer de laringe / Protocol of laryngeal cancer management

Este trabalho visa apresentar uma proposta de protocolo para tratamento de pacientes portadores de carcinoma epidermóide da laringe atendidos no Setor de Cirurgia de Cabeça e Pescoço do Hospital Universitário, Hospital de Caridade e Centro de Pesquisas Oncológicas - CEPON-(NICAP-Núcleo Integrado de Cabeça e Pescoço). O mesmo inclui uma breve revisäo da literatura no que tange à epidemiologia, fatores de risco, anatomia da laringe e das cadeias linfáticas cervicais, bem como a classificaçäo clínica e do estadiamento empregados na avaliaçäo destes casos. Com a sua aplicaçäo, os resultados seräo analisados procurando avaliar a eficácia da terapêutica aplicada.

Hemiagenesia de tireóide: relato de quatro casos / Thyroidal hemiagenesis: report of four cases

Há pouco mais de 130 casos de hemiagenesia de tireóide na literatura. Mais quatro säo relatados no presente artigo: todos eram mulheres sem alteraçöes hormonais, duas tinham discreto aumento no volume do pescoço. A suspeita foi levantada ao mapeamento com iodo radiativo e confirmada com o estímulo pelo TSH exógeno e a ultra-sonografia, que mostraram ausência do lobo esquerdo em três dos casos e, do lobo direito no caso restante. Näo havia alteraçöes patológicas no lobo remanescente e todas se encontram assintomáticas até o momento